Revisiting dengue: Look for rise in hematocrit and not just falling platelets

Whenever dengue strikes, platelet counts along with shortage of platelets become the high point of discussion and panic sets in. Because it is presumed that platelet transfusion is the main treatment option for dengue. This is not so.

Platelet transfusions are not needed unless the platelet counts are less than 10,000 or there is active bleeding and thickening of blood.

Dengue causes low platelet count, but low platelet count by itself is never dangerous because patients with heart disease, diabetes are prescribed antiplatelets like aspirin, where they have a beneficial effect in preventing thrombotic complications. They are asked to report if they develop bleeding while on antiplatelets. Patients with idiopathic thrombocytopenic purpura (ITP) always have a low platelet count and they live a normal life on medication.

It’s not the platelet count alone with determines the prognosis of a patient of dengue.

More than the falling platelet count, it is the rapidity of fall in platelet count that is important. Even this does not alone is indicative of severity of illness.

Dengue not only causes low platelet count or destroys platelets, it also causes endothelial damage. Capillary leakage manifests as hemoconcentration and leads to increase in hematocrit and/or MCV and this is important. This is a medical emergency because a rising hematocrit means intravascular dehydration, which leads to multiorgan failure, hypotension and death.

Therefore, it is the rise in hematocrit along with rapid fall in platelets, which is the danger sign and is indicative of impending severe dengue.

Here is a simple Formula of 20 to identify high risk patients 

·         Rise in pulse by 20

·         Fall in upper blood pressure by more than 20

·         Rise in hematocrit by more than 20%

·         Rapid fall in platelets to less than 20,000

·         More than 20 hemorrhagic spots on the arm in one inch after tourniquet test

·         Difference between upper and lower BP is less than 20

Start fluid replacement at 20 ml/kg/hour immediately in such patients, and shift to nearest medical center for observation. 

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Harm Reduction 2 : “Less harmful alternatives to tobacco”

Continuing our series on Harm reduction, we present the views of Jeannie Cameron, Founder and MD JCIC International, a UK-based strategic advocacy consultancy specializing in tobacco harm reduction. She also attended the seminar on “Harm Reduction” organized on 27th September at IIC, New Delhi.

When I spoke to her about tobacco harm reduction and e-cigarettes, this is what she had to say.

“There is a product called Swedish snus, which is like pasteurized smokeless tobacco product that you put in the mouth. Sweden has this product historically for 300 years. In Sweden, which is very good at its medical health and epidemiology, they have studied this for more than 50 years, and found zero or nil deaths from tobacco snus product.  Norway, next door in Scandinavia, also has started to use this product and also found zero deaths from it. When you compare that with a country like India which has significant use of oral and smokeless (tobacco) and you have huge deaths – 30-40% of tobacco related deaths are coming from that.

In Sweden, they were so wanting to ensure that they didn’t want to lose this product that when they joined the European Union (EU) in the 1970s, they have a special derogation in the law under the treaty to join EU to protect their use of this product. That’s how important it was for Sweden at the time. And the evidence everyone who is anywhere in the world, anyone would tell that it is less harmful than smoking.

I am not an expert on e-cigarettes so much because  when I did my legal dissertation at the time in 2007 on harm reduction and tobacco harm reduction, e-cigarettes were not even available. They were not really discovered then. So this information has come later.

The Royal College of Physicians and all the research that is coming in now – independent research, some research is coming from tobacco companies, but they put it out for independent scrutiny – it is all showing and the RCP saying that it is up to 95% less harmful than smoking.  

There are three products available now, which are less harmful than smoking.

One is Swedish snus, which is significant in Sweden. The other one is e-cigarettes; UK has now the fastest fall in smokers since they have been available because the UK allows them freely.

And, vaping is taking off all over the world as smokers find it’s a good replacement.

The third is the heated tobacco, which is launched in Japan only two years ago. It’s already something like 27% of Japanese smoking market. Japanese are known to be big smokers and they have switched over to using heated tobacco. Japan does not allow e-cigarettes, but they allow heated tobacco.

The way to think about is both these products are vaping because they are not producing smoke, whether it is a heated tobacco or whether it is an e-cigarette. They are producing vapor and vapor is not causing any harm to the lung like smoke is.

And as we know, it’s the nicotine they want … they smoke for nicotine, but they die from the smoke.

If we can provide people with something that is helpful to them in terms of their health, but still gives them the nicotine that they want, then that’s a much better thing. In India, that could make a huge difference.

All the time, there are new developments being made on nicotine, and nicotine is now being used to help cases of Parkinson’s, Alzheimer’s ... I think in the future there will be lot of emerging research, which will show that.  

But, I think, one of the big concerns also is the tax side and of the growers and economies which are dependent on tobacco should see it as potentially for future business opportunity in some respects because it is transitioning people. They don’t need to be afraid of it and in some parts of the world, where there are big growing places like Brazil or Indonesia and maybe a bit in India, they should see it as an opportunity.”

Declared dead by doctors in UP, elderly man comes alive

Always rule out hypothermia and Lazarus syndrome in critically ill patients before declaration of death

Dr KK Aggarwal and Advocate Ira Gupta

Doctors at a private Ram Shiva hospital in Kanpur declared a 55-year-old road accident victim Phool Singh dead on Sunday, but he regained senses while being shifted to the mortuary at Lala Lajpat Rai hospital for postmortem on the same day. He was immediately taken back to the hospital by his relatives, where he died while undergoing treatment several hours later on Monday. His kin have filed a complaint to the police, who are investigating the matter.

Quoting Singh's family, the police said he had sustained critical injuries in a road accident in Fatehpur on Sunday morning and was admitted to Rama Shiv hospital in Kanpur. After preliminary treatment, doctors at the hospital declared Singh dead around 4pm the same day and allegedly issued a death certificate. However, while his body was being shifted to the mortuary, his family members found him 'breathing' and informed the doctors who later confirmed that he was alive.

One possible scenario that may explain this situation is that the patient was in extreme hypothermia, which went unrecognized, and the patient died later on. In extreme hypothermia, a person can be mistaken as clinically dead while he is not

Hypothermia in adults is defined as core temperature below 35°C. According to severity, hypothermia can be:

·         Mild (core temperature 32 to 35°C)

·         Moderate (core temperature 28 to 32°C)

·         Severe (core temperature below 28ºC)

Stage 1 hypothermia as described by the International Commission for Mountain Emergency Medicine is mild hypothermia with normal mental status with shivering.

Stage 2 hypothermia is moderate hypothermia with impaired mental status; shivering may be or may not be present.

In stage 3 hypothermia (severe; core temperature 24 to 28°C), the person is unconscious.

Stage 4 hypothermia (severe; core temperature 13.7 to 24°C) is apparent death but resuscitation may be possible.

Stage 5 hypothermia is death due to irreversible hypothermia and it is not possible to resuscitate the person.

Let’s take a look at the basic physiologic changes that take place in hypothermia.

Cooling decreases tissue metabolism and inhibits neural activity. In mild hypothermia, shivering due to skin cooling generates heat and increases metabolism, ventilation, and cardiac output. As the body temperature falls, the cold slows down metabolism. Once the core temperature reaches 32°C, metabolism, ventilation, and cardiac output begin to decline and shivering becomes less effective in retaining heat until it finally stops as core body temperature continues to decline. For each 1°C fall in body temperature, the body metabolism slows by around 6%; at 28°C, the basal metabolic rate is about half of normal.

Neurologic function begins declining even above a core temperature of 35°C. Patients often lose consciousness; vital signs may be absent. Presence of muscle rigidity without shivering can be mistaken for rigor mortis. The absence of shivering and presence of stupor, skin flushing, muscle rigidity, hypoventilation, and circulatory failure means very cold patients often appear dead rather than hypothermic. But in this stage of severe hypothermia (core temperature <28°C or 82°F), a suspended metabolism may protect against hypoxia.

Stage 4 hypothermia must be excluded, which is the stage where it is still possible to revive the patient. Failure to recognize the condition of hypothermia may be the reason why severely hypothermic patients are sometimes pronounced dead. It may be possible to successfully revive a person if recognized in time. No patient therefore should be declared dead without measuring rectal temperature.

A similar situation can also occur in the following conditions: 

·         Lazarus syndrome, also known as autoresuscitation, after failed cardiopulmonary resuscitation is the spontaneous return of circulation after failed attempts at CPR due to buildup of pressure in the chest as a result of CPR. The relaxation of pressure after resuscitation efforts have ended is thought to allow the heart to expand, triggering the heart's electrical impulses and restarting the heartbeat. Other possible factors are hyperkalemia or high doses of adrenaline.

·         Deep coma mistaken as clinical death

·         Apathy in dealing with terminal cases and believing the paramedical staff

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Zika & the oncoming marriage season

Dr KK Aggarwal

A total of 22 positive laboratory confirmed cases of Zika virus infection have been detected so far in Jaipur, Rajasthan. And, this number will only rise. On Sunday, the Health Ministry sounded an alert for Bihar after a student of computer science from Siwan, studying in Jaipur, tested positive for the Zika virus. He was in Siwan between August 28 and September 12 to appear for an exam.

Zika virus is gaining foothold in India and is now here to stay. Public awareness about Zika is low and diagnostic facilities are not available everywhere.

In August 2018, the Centers for Disease Control and Prevention (CDC) released updated guidelines for preconception counseling and prevention of sexual transmission of Zika virus for men with possible Zika virus exposure.

CDC now recommends that men with possible Zika virus exposure who are planning to conceive with their partner wait at least 3 months after symptom onset (if symptomatic) or their last possible Zika virus exposure (if asymptomatic) before engaging in unprotected sex to prevent sexual transmission of Zika virus and also to reduce the risk for fetal Zika virus infection.

Relevant exposure is defined as residence in or travel to an area where mosquito-borne transmission of Zika virus infection has been reported, or unprotected sexual contact with a person who meets these criteria.

For couples who are not trying to conceive, CDC recommends that men can consider using condoms or abstaining from sex for at least 3 months after symptom onset (if symptomatic) or their last possible Zika virus exposure (if asymptomatic) to minimize their risk for sexual transmission of Zika virus.

Winter season is on the horizon and so is the marriage season. In India, the marriage season will commence from the end of Chaturmas in November.

All newly-weds should avoid starting a family if one of them has or is recovering from dengue-like illness. Rule out Zika virus infection first.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

 

Keto diet may not be safe

Excerpts from Harvard Health Letter

Low-carb, high-protein diets often grab attention. The Paleo, South Beach, and Atkins all fall into this category. They are also called ketogenic or "keto" diets.  But a true ketogenic diet unlike other low-carb diets (which focus on protein) centers on fat, which supplies as much as 90% of daily calories.

The keto diet is primarily used to help reduce the frequency of epileptic seizures in children. For weight loss only short-term results are available. We don't know if it works in the long term, nor whether it's safe.

The keto diet aims to force your body into using a different type of fuel. Instead of relying on sugar (glucose) that comes from carbohydrates (such as grains, legumes, vegetables, and fruits), the diet relies on ketone bodies (fuel that the liver produces from stored fat).

Burning fat seems like an ideal way to lose pounds. But getting the liver to make ketone bodies is tricky. It requires that you deprive yourself of carbohydrates, fewer than 20 to 50 grams of carbs per day (medium-sized banana has 27 grams of carbs). It typically takes a few days to reach a state of ketosis and eating too much protein can interfere with ketosis.

Because the keto diet has such a high fat requirement, followers must eat fat at each meal. In a daily 2,000-calorie diet, that might look like 165 grams of fat, 40 grams of carbs, and 75 grams of protein.  Some healthy unsaturated fats are allowed on the keto diet — like nuts (almonds, walnuts), seeds, avocados, tofu, and olive oil. But saturated fats from oils (palm, coconut), lard, butter, and cocoa butter are encouraged in high amounts. Protein is part of the keto diet, but it doesn't typically discriminate between lean protein foods and protein sources high in saturated fat such as beef, pork, and bacon.

All fruits are rich in carbs, but you can have certain fruits (usually berries) in small portions. Vegetables (also rich in carbs) are restricted to leafy greens (such as kale, Swiss chard, spinach), cauliflower, broccoli, Brussels sprouts, asparagus, bell peppers, onions, garlic, mushrooms, cucumber, celery, and summer squashes. A cup of chopped broccoli has about six carbs.

Ketogenic diet has numerous risks.

·         It’s high in saturated fat. One is supposed to keep saturated fats to no more than 7% of your daily calories because of the link to heart disease. Keto diet is associated with an increase in "bad" LDL cholesterol, which is also linked to heart disease.

·         If you’re not eating a wide variety of vegetables, fruits, and grains, you may be at risk for deficiencies in micronutrients, including selenium, magnesium, phosphorus, and vitamins B and C.

·         With so much fat to metabolize, the diet could make any existing liver conditions worse.

·         The kidneys help metabolize protein, and the keto diet may overload them. (The current recommended intake for protein averages 46 grams per day for women, and 56 grams for men).

·         The keto diet is low in fibrous foods like grains and legumes. It can lead to constipation.

·         The brain needs sugar from healthy carbohydrates to function. Low-carb diets may cause confusion and irritability.

The popular low-carb diets (such as Atkins or Paleo) modify a true keto diet. But they come with the same risks if you overdo it on fats and proteins and lay off the carbs.

(Source: Harvard Health Letter (Dept. of Nutrition at Harvard-affiliated Brigham and Women's Hospital)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

 

Should the opposition always criticize the government?

Opposition is an important and integral part of democracy, which is a government of the people, by the people and for the people.

We have two main national political parties in the country; both have a country-wide presence down to the grassroots level.

But, every day we either read, or see that the opposition only criticizes the government, without any constructive suggestion or views. Being in the opposition does not just mean to always oppose the government in every action or every policy decision it takes. This only reduces the growth and development of the country.

While the main role of the Opposition is to question the government and hold them accountable to the public, it shares equal responsibility with the government to act in the best interests of the citizens.

The Opposition should participate in all policies, programsand matters of national interest in a constructive manner. If they do not agree with the government projects on merit, they should come out with constructive initiation and undertake parallel projects. The idea is not to work only when in power. They can do CSR projects and get enough funding to work, as long as they have the desire to work.

For example, if the opposition does not agree with Ayushman Bharat scheme, they should come out with a scheme, which is better than Ayushman Bharat.

And, instead of only criticizing the government on construction of toilets as part of the Swachh Bharat Abhiyan to make the country open defecation free (ODF), the opposition can adopt villages and construct better toilets there for people to use, as a scheme that is more successful than the ODF scheme of the government.

A large percentage of the population still defecates in the open, although this number is coming down. Elimination of open defecation is a hugely ambitious goal, yet an admirable one. Change in public behavior could go a long way in making this program a success. If the opposition cannot come out with a better scheme, they should participate wholeheartedly in this mission and join hands with the government to make it a success.Being ODF means being free of many infectious diseases.They can help in bringing about a behavioral change by educating the public about the benefits of sanitation and waste management.

This holds true for politics everywhere. A strong and vigilant opposition, which is constructive in its approach to all matters of national interest, has a lot to contribute to national development.

“The opposition is indispensable. A good statesman, like any other sensible human being, always learns more from his opposition than from his fervent supporters”said, Walter Lippmann, an American writer and political commentator.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

 

Harm Reduction: The Canada way

Harm reduction is gaining popularity as a public health strategy to reduce the potential risks associated with health behaviors. We’ll be coming out with a series of articles and viewpoints on harm reduction in the future. Here is the first one.

A seminar on “Harm Reduction” was organized on September 27^th at IIC, New Delhi to discuss how alternates to nicotine and tobacco products can potentially reduce harm caused by smoking and oral tobacco use.

I spoke to Prof David Sweanor on the side-lines of the seminar about what Canada and the medical community in Canada thinks about e-cigarettes given that the Health Ministry in India recently issued an advisory to states/UTs to ensure that ENDS are not sold, manufactured, distributed, traded, imported and advertised in any manner.

Prof David Sweanor is Chair of Advisory Board, Centre for Health Law, Policy and Ethics, University of Ottawa in Canada.

This is what he had to say.

“The Canadian government years ago thought the way to deal with things like vaping was to ban the products. What we have ended up with is recognizing that these products are massively less hazardous than cigarettes and that we need to encourage smokers to move to these products. So, now Health Canada is actually talking about how do you give more information to people and how do you move more smokers to products like vaping.

More and more of the medical community in Canada is moving the way we have seen in the UK. In the UK, the Royal College of Physicians, British Medical Association, Action on Smoking and Health, Cancer Research UK ...all the major health and medical organizations have now come on board saying that this is what we need to do; we need to try to encourage people to move to less hazardous products and vaping is less hazardous than smoking cigarettes. We should encourage it.

It’s very hard for us to have the number of those who have switched from cigarettes to e-cigarettes in Canada now. The surveys are not done yet. In the UK, 3 million people are vaping. In the US, there are several million who are vaping; there are about five and half million exclusive vapers i.e. they don’t smoke cigarettes any more.

Estimates from very prestigious bodies like Royal College of Physicians saying based on all the science and everything that we know, vaping is likely to be at least 95% less hazardous than smoking cigarettes. So, we can never say anything is risk-free, but we know that some things are less risky than others.

The history of public health has been very pragmatic to say that we may not be able to eliminate risk, but what we can do is to make it less risky. For example, we can make automobiles such that they are less likely to injure or kill people that are inside them.

When phasing out, give people some alternatives – something else to use instead. So, the idea is that if we are trying to ban something that people are using, particularly if it is something that they are addicted to, or acculturated to, we need to change the behavior and that is why we have moved to things like people wearing seat belts in cars. This is not saying don’t use a car, but when in a car, use seat belt. There are rules about not drinking and driving in many countries. This is not to say that driving isn’t safe, drinking and driving is not safe.”

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA